DOI: 10.1111/tog.12064 2014;16:29–36 Review The Obstetrician & Gynaecologist http://onlinetog.org

Nerve injuries associated with gynaecological surgery

a b, a Olayemi Kuponiyi MRCOG, Djavid I Alleemudder MRCOG MRCS(Ed) BSc, * Adeyinka Latunde-Dada BMBS BMedSci, c Padma Eedarapalli MD MRCOG aSpecialist Trainee, Queen Alexandra Hospital, Southwick Hill Road, Cosham, Portsmouth PO6 3LY, UK. bSpecialist Trainee, Salisbury NHS Trust, Odstock Road, Salisbury SP2 8BJ, UK. cConsultant Obstetrician & Gynaecologist, Royal Bournemouth Hospital, Castle Lane East, Bournemouth BH7 7DW, UK *Correspondence: Djavid Alleemudder. Email: [email protected]

Accepted on 24 September 2013

Key content Learning objectives  injuries are a common complication of gynaecological  To gain an overview of the spectrum of different neuropathies that surgery, occurring in 1.1–1.9% of cases. may occur following pelvic surgery.  Patient mal-positioning, incorrect placement of self-retaining  To learn about safe surgical techniques in the prevention of retractors, haematoma formation and direct nerve entrapment or postoperative neuropathies. transection are the primary causative factors in perioperative  To review the clinical anatomy of the lumbo-sacral and nerve injury. brachial plexuses.  most commonly injured during surgery include the Ethical issues femoral, ilioinguinal, pudendal, obturator, lateral cutaneous,  Neuropathies can cause considerable postoperative morbidity. iliohypogastric and genitofemoral nerves.  Should neuropathies following gynaecology surgery be discussed  The majority of neuropathies resolve with conservative routinely during consent taking? management and physiotherapy.  Neuropathies following surgery may have considerable  Selective serotonin reuptake inhibitors (SSRIs), tricyclic medico-legal implications. antidepressants and gamma-aminobutyric acid (GABA) antagonists are of significant benefit in managing Keywords: gynaecological surgery / nerve injury / neuropathy painful neuropathies.

Please cite this paper as: Kuponiyi O, Alleemudder DI, Latunde-Dada A, Eedarapalli P. Nerve injuries associated with gynaecological surgery. The Obstetrician & Gynaecologist 2014;16:29–36.

Introduction and parasympathetic injuries to the nervous supply of the bladder and bowel are beyond the scope of this article. Iatrogenic nerve injury following gynaecological surgery occurs more commonly than is recognised and is a Pathophysiology of nerve injury significant cause of postoperative neuropathy. Patient mal-positioning, improper incision sites and self-retaining Neuropathy results when there is a disruption to the blood retractors are major contributors to the origins of supply of the nerve caused by injury. Three types of intraoperative gynaecological nerve injury. microvascular changes occur with nerve injury (Table 1). The incidence of neuropathy following gynaecological Neuropraxia is the result of external nerve compression – surgery is between 1.1 and 1.9%.1 3 The majority of cases leading to a disruption of conduction across a small portion will have a good prognosis, with minimal or no of the axon. Nerve recovery takes weeks or months once intervention necessary for resolution of the neurological remyelination occurs. impairment. A minority of patients sustain long-term Axonotmesis is caused by profound nerve compression or complications necessitating prolonged treatment or even traction. Damage occurs to the axon only, with preservation reparative surgery. of the supporting Schwann cells. Regeneration is possible In this article the authors outline the anatomy of the because supporting Schwann cells remain intact. Recovery susceptible nerves, describe the common mechanisms of time is longer than neuropraxia. injury and discuss the management of such injuries. The The most severe form of injury is termed neurotmesis, and preventative strategies to reduce neuropathies and the it results from complete nerve transection or ligation, where medico-legal ramifications are also discussed. Sympathetic both the axon and Schwann cells are disrupted. Regeneration

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Table 1. Pathophysiology of nerve injury

Type of nerve injury Pathophysiology Prognosis

Neuropraxia External nerve compression Recovery within weeks to months Axonotmesis Severe compression with axon damage Recovery takes longer usually several months Neurotmesis Nerve transection with damage to Schwann cells Poor prognosis without restorative surgery

is rendered impossible and without restorative surgery, Entrapment nerve injuries are more commonly prognosis is usually poor.2,4 encountered in pelvic floor reconstruction surgery. Pain is a common symptom of nerve entrapment in contrast to loss Mechanism of nerve injury of function and numbness that occurs with nerve transection. A recent study showed that chronic nerve-related pain was The mechanism of intraoperative nerve injury involves a seen in 7% of women following Pfannenstiel incisions and combination of compression, stretch, entrapment or this was attributed to entrapment of the ilioinguinal and transection of nerve fibres.3 iliohypogastric nerves.8 Compression and stretch injuries are typically caused by Although rare, another source of perioperative improper placement of self-retaining retractors such as the lumbosacral nerve injury to consider is related to Balfour or Brookwalter retractors5,6 and in prolonged complications of regional anaesthesia. During epidural or positioning of the patient in stirrups. spinal neuraxial blockade, poor technique may cause Transection injuries are largely related to incorrectly sited paraesthesia and pain as a result of needle or catheter tip surgical incisions. The Pfannenstiel and low transverse trauma to nerve roots and the spinal cord. Pain may also incisions are the most common incisions performed in result from injection of anaesthetic into the wrong spinal gynaecology. Should these incisions extend beyond the compartment. Most often, neurological damage secondary lateral margin of the inferior rectus abdominus muscle, the to regional anaesthesia administration is immediately lateral cutaneous branches of the iliohypogastric and apparent as the patient becomes symptomatic during ilioinguinal nerves are liable to be injured (Figure 1). A the procedure.9,10 cadaver study found that abdominal wall incisions below the level of the anterior superior iliac spine and Specific nerve anatomy and related approximately 5 cm superior to the pubic symphysis had neuropathies the greatest potential for injuring the ilioinguinal or iliohypogastric nerves.7 The nerves most commonly injured during pelvic surgery originate from the lumbosacral and brachial plexuses (Figures 2 and 3). Table 2 provides a summary of the nerve components of the , their function and clinical presentation after injury.

Femoral nerve The originates from nerve roots L2–L4. It passes infero-laterally through the psoas muscle and emerges from its lateral border. It exits the pelvis beneath the , lateral to the femoral vessels to enter the thigh. Gynaecological surgery is the most common contributor to iatrogenic femoral nerve injury, and abdominal hysterectomy is mostly responsible for this.11 Of all reports of gynaecological associated neuropathy, the femoral nerve is most frequently implicated, with an incidence of at least 11%.12 Femoral neuropathy commonly occurs as a result of compression of the nerve against the pelvic sidewall as it Figure 1. Ilioinguinal and iliohypogastric nerves in relation to lower emerges from the lateral border of the psoas muscle. This transverse abdominal incision. happens when excessively deep retractor blades are used or

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of the hip results in kinking of the femoral nerve under the inguinal ligament.13 Femoral neuropathy presents with weakness of hip flexion and adduction and knee extension. There is loss of the knee jerk reflex and paraesthesia over the anterior and medial thigh, as well as the medial aspect of the calf.

Ilioinguinal and iliohypogastric nerves The T12–L1 nerve root gives rise to the ilioinguinal and iliohypogastric nerves. Both nerves pass laterally through the head of the psoas muscle before running diagonally along quadratus lumborum. The pierces the external oblique aponeurosis above the superficial inguinal ring, while the emerges through it. Both nerves have a sensory function only. While the Iliohypogastric provides sensation to the skin of the gluteal Figure 2. Lumbosacral plexus. Reproduced with permission from and hypogastric regions, the ilioinguinal nerve provides Gray JE. Nerve injury associated with pelvic surgery. In: UpToDate, sensory innervation to the skin overlying the groin, inner Basow DS (Ed), UpToDate, Waltham, MA 2013. Copyright thigh and . ª UpToDate, Inc. For more information visit www.uptodate.com. Injury to these nerves is typically caused by suture entrapment at the lateral borders of low transverse or Pfannenstiel incisions that extend beyond the lateral border of the rectus abdominus muscle. The reported incidence of ilioinguinal or iliohypogastric neuropathy following a Pfannenstiel incision is 3.7%.15 Laparoscopic and retropubic mid urethral tape procedures may also injure this nerve.16 The diagnostic triad for ilioinguinal/iliohypogastric nerve entrapment syndrome consists of: 1. sharp burning pain radiating from the incision site to the , labia and thigh, 2. paraesthesia over the nerve distribution areas, 3. pain relief following administration of local anaesthetic.

Genitofemoral nerve The genitofemoral nerve (L1–L2) transverses the anterior surface of psoas, and lies immediately lateral to the external iliac vessels. It divides into a genital branch, which enters the deep inguinal ring, and a femoral branch, which passes deep to the inguinal ligament within the . Figure 3. Brachial plexus. Reproduced with permission from Gray JE. Nerve injury associated with pelvic surgery. In: UpToDate, Basow DS This nerve is susceptible to injury during pelvic sidewall (Ed), UpToDate, Waltham, MA 2013. Copyright ª UpToDate, Inc. For surgery and during removal of the external iliac nodes. more information visit www.uptodate.com. Genitofemoral nerve injury results in paraesthesia over the mons pubis, labia majorum and . during the lateral placement of retractors. In a 10-year prospective study, Goldman et al13 reported an 8% incidence Lateral cutaneous nerve of femoral neuropathy when self retaining retractors were The lateral cutaneous nerve of the thigh (L2–L3) also emerges used during gynaecological surgery, compared to an from the lateral border of psoas. It crosses the iliac fossa incidence of <1% when not used.14 anterior to the iliacus muscle and enters the thigh posterior Inappropriate patient positioning in lithotomy is also to the lateral end of the inguinal ligament. another cause of stretch-related femoral neuropathy The mechanism of injury during pelvic surgery to this (Figure 4). Hyper-flexion, abduction and external rotation nerve is similar to that of the femoral nerve.

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Table 2. Summary of lumbosacral plexus

Nerve Origin Sensory function Motor function Clinical presentation

Femoral L2–L4 Anterior/medial thigh, Hip flexion/adduction Unable to climb stairs medial aspect calf Knee extension Obturator L2–L4 Upper medial thigh Thigh adduction Minor ambulatory problems Sciatic L4–S3 Below knee except medial foot Hip extension/knee flexion Sciatica - Common peroneal Lateral calf, dorsum foot Dorsiflexion/eversion foot Foot drop - Tibial Toes, plantar surface foot Plantar flexion/inversion foot Cavus deformity foot Iliohypogastric T12–L1 Mons, lateral labia, upper None Sharp, burning pain radiating from inner thigh incision site to mons, labia, or thigh Ilioinguinal T12–L1 Groin, symphysis None Same as above but to groin, symphysis Pudendal S2–S3 Perineum None Perineal pain Lateral cutaneous nerve L2–L3 Anterior/posterio-lateral thigh None Pain/paraesthesia anterior/postero-lateral thigh (meralgia paraesthetica) Genito-femoral L1–L2 Labia, femoral triangle None Pain/paraesthesia labia, femoral triangle

Sciatic and The arises from the L4–S3 nerve roots. It emerges from the pelvis below the piriformis muscle, curving laterally and downward through the gluteal region. Initially it lies midway between the posterior superior iliac spine and ischial tuberosity. Lower down in the thigh it courses midway between the ischial tuberosity and greater trochanter. The common peroneal nerve and are its two derivatives at the mid-thigh. The common peroneal nerve importantly winds forward around the neck of the fibula. The sciatic and peroneal nerves are commonly injured at the sciatic notch and the lateral aspect of the fibular neck respectively. Both nerves are susceptible to stretch injuries from hyperflexion of the thighs in improper lithotomy positions. Furthermore, the common peroneal nerve may be Figure 4. Hyperflexion of hips while in candy cane stirrups. Figure reproduced from Bradshaw et al.4 with permission from the authors. compressed at the fibular neck in lithotomy. Sciatic nerve injury presents as sensory impairment below Symptoms of injury include paraesthesia and pain in the knee and weakness of hip extension and knee flexion. the anterior and posterio-lateral thigh (referred to as Foot drop is reported when the common peroneal nerve is meralgia paraesthesia). injured, along with paraesthesia over the calf and dorsum of the foot. The anterior branches of L2–L4 give rise to the obturator nerve and converge behind the psoas muscle. The obturator The pudendal nerve (S2–S4) exits the pelvis initially through nerve then passes over the pelvic brim in front of the the greater sciatic foramen below the piriformis. Importantly, sacroiliac joint and behind the common iliac vessels to enter it runs behind the lateral third of the sacrospinous ligament the thigh via the obturator foramen. and ischial spine alongside the internal pudendal artery and This nerve is most frequently injured during immediately re-enters the pelvis through the lesser sciatic retroperitoneal surgery, excision of endometriosis, the foramen to the pudendal canal (Alcock’s canal). passage of a trocar through the obturator foramen, This nerve is susceptible to entrapment injuries during insertion of transobturator tapes and during paravaginal sacrospinous ligament fixation as it runs behind the lateral defect repairs. aspect of the sacrospinous ligament. Obturator neuropathy will present with sensory loss in The patient will report postoperative gluteal, perineal and the upper medial thigh and motor weakness in the vulval pain, which worsens in the seated position if the nerve hip adductors. is damaged.17

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Table 3. Summary of brachial plexus

Nerve Origin Sensory function Motor function Clinical presentation

Ulnar C8–T1 Medial 1½ fingers Small muscles of hand Claw hand Radial C5–T1 Dorsal tips of lateral 3½ fingers Wrist and finger extension Wrist drop, unable to extend fingers Erb’s palsy C5–C6 None Abduction of shoulder, flexion of Waiters tip elbow, supination Klumpke’s palsy C8–T1 Medial arm/forearm/hand and Intrinsic muscles of hand Claw hand medial 2 fingers

The disruption of neurological pathways secondary to the elbow during arm board positioning can compress the gynaecological surgery has been postulated as an aetiological ulnar nerve as it winds around the medial epicondyle. This factor for female sexual dysfunction.18 Some studies results in sensory loss in the tips of the medial 1½ fingers found that sexual dysfunction was evident postoperatively and a ‘claw hand’ from paralysis of the small muscles of following disruption of the pudendal nerve sensory the hand. pathway.19 However, evidence for this conclusion is quite Stretch injuries are the most common mechanism of injury limited, as only a handful of clinical studies to date to the brachial plexus.14 Hyper-abduction of the arm may have investigated neurologic sensory deficits as a cause of result in a lesion of the upper nerve roots of the brachial sexual dysfunction. plexus, involving nerves (C5–C6). This typically occurs when arm boards are extended beyond 90 degrees from the long The brachial plexus axis of the operating table or when the arm unknowingly falls The brachial plexus originates from nerve roots C5–T1. It from the arm board during a procedure (Figure 5). As a supplies the upper limb and lies within the posterior triangle result, the arm hangs by the side, and is medially rotated and of the neck (Table 3). pronated. This is known as Erb’s palsy or ‘waiter’s The radial nerve leaves the posterior compartment of the tip’ deformity. arm by winding around a spiral groove on the back of the Brachial plexus injuries have also been reported when humerus. Pressure on the humerus during arm positioning shoulder braces are used to provide patient support in the can result in sensory loss in the lateral 3½ fingertips and steep Trendelenburg position during laparoscopic surgery. paralysis of the wrist and finger extensors. The lower brachial plexus nerve roots (C8–T1) are stretched The ulnar nerve arises from the medial cord and enters if the brace is positioned too laterally (Figure 6). This results the forearm posterior to the medial epicondyle of the in a Klumpke’s palsy, with loss of the function of the small humerus. Undue pressure placed on the medial aspect of muscles of the hand.

Figure 5. Upper extremity abducted greater than 90 degrees on arm Figure 6. Incorporation of shoulder braces during steep 4 board. Figure reproduced from Bradshaw et al. with permission from Trendelenburg. Figure reproduced from Bradshaw et al.4 with the authors. permission from the authors.

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Treatment of nerve injuries during gynaecological operations. Also crucial in preventing nerve injury is the preoperative identification of patients who Neuropathies presenting postoperatively require a careful are more prone to neurological complications. Studies have history and examination to identify the extent and probable shown that patients who have a thin body habitus, mechanism of nerve injury. All too often patients’ neuropathic ill-developed abdominal wall muscles or a narrow pelvis are – complaints are dismissed in the setting of residual anaesthesia, more at risk of retractor blade associated nerve injury.14,21 23 incision pain and postoperative analgesia, especially during Such patients are at further risk if the operating time the acute postoperative period. It is also important to exceeds 4 hours. distinguish iatrogenic nerve injury from other postoperative A large number of iatrogenic lumbosacral nerve injuries neurological complaints such as musculoskeletal injury and during gynaecological surgery can be attributed to the autoimmune or inflammatory conditions. incorrect positioning of self-retaining retractor blades. The Fortunately, most neuropathies will resolve spontaneously, gold standard of correct positioning is for the self-retractor with minimal intervention. Sensory neuropathies typically blades to cradle the rectus muscle without compressing the resolve within 5 days, whereas motor deficits may take up to psoas muscle underneath. 10 weeks to recover. Occasionally neuropathies persist When positioning the retractors, the surgeon must check beyond 1 year. visually and by direct palpation that the psoas muscle is not Detailed neurological examination and electromyographic entrapped between the blades and the pelvic side wall. (EMG) studies are key to diagnosing a neurologic deficit. Furthermore, the shallowest retractor blade sufficient to Once a neuropathy has been identified, the patient should be providing adequate exposure should be chosen, as it has referred to a neurologist. EMG is useful in identifying and been suggested that the degree of nerve injury is localising acute nerve injury by measuring sensory and motor proportional to blade length.24 Rolled up laparotomy pads nerve conduction velocity. With intraoperative nerve injuries, may be used to cushion the retractor blades against the EMG should be performed 3–4 weeks from the point of pelvic side wall as a precaution. Retractor blade position suspicion of nerve damage, as denervation of the afflicted should be monitored intermittently during the operation muscle is often delayed.20 and re-adjusted accordingly. Acutely, the management of neuropathies should be The authors recommend undoing the retractors and dictated by the symptoms presented. Painful neuropathies re-positioning at regular intervals to relieve blade pressure often respond to pharmacological agents known to be effective against the pelvic side wall if a lengthy operation is being in the treatment of neurogenic pain, such as, tricyclic undertaken. As hand-held retractors will only exert anti-depressants and gamma-aminobutyric acid (GABA) intermittent as opposed to continual pressure on retracted antagonists. Painful neuropathies rarely fail to resolve after tissue, they should be selected over self-retaining ones 6 months. In such cases, local nerve blockade or even surgical wherever possible.14 nerve excision or decompression can be considered. Particular attention must be paid to the correct Motor impairment from retraction or stretch-related nerve preoperative positioning of the patient in lithotomy injuries during improper patient positioning should be stirrups. The proper lithotomy position dictates that the managed by physiotherapy, so as to maintain flexibility and hip and knee are only moderately flexed. At the hip, there range of movement. Active use of the muscles afflicted is should be minimal abduction and external rotation. The generally recommended, although splinting may be stirrups or boots should be at equal height. Excessive protective against further injury. movement around the hip joint results in stretch and/or Nerve lesions that do not heal are often the result of compression of the sciatic and femoral nerves. complete nerve transection. These nerves may be amenable to Common peroneal nerve injury is avoided when there is specialist repair using microsurgical techniques, such as padding in place between the lateral fibular heads and the tension-free end-to-end anastomosis. The aim is to regain stirrup, thus preventing nerve compression against a hard alignment of the epineurial sheath and neural fascicles. surface. As with abdominal surgery, the length of operative Repair of a transected obturator nerve has been shown to time during lithotomy has been cited as a significant risk have an excellent prognosis with complete motor recovery factor for increasing the risk of nerve injury, especially if – after physiotherapy.14 operating time exceeds 2 hours.25 28 A surgeon should avoid extending his incision beyond the Prevention of nerve injuries lateral margins of the rectus muscles, where the ilioinguinal and iliohypogastric nerves lie. If wide margins are necessary, A thorough and complete understanding of the anatomy of upward curving incisions should be made to avoid the path the lumbosacral and brachial nerve plexuses by the surgeon is of the underlying nerves. During fascial closing of low absolutely integral to minimising the risk of nerve injury abdominal incisions, care must be taken to incorporate tissue

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Most cases are self-limiting, and symptoms resolve within several weeks. However, the authors believe that a thorough understanding of the pelvic anatomy and proper placement of self-retaining retractors can prevent most nerve injuries that are related to gynaecology surgery.

Disclosure of interests None declared.

Acknowledgements We would like to thank: Amber D. Bradshaw and Arnold P. Advincula for permission to use Figures 4–7. We would also like to thank Uptodate Inc. for use of Figures 2 and 3.

Figure 7. Proper placement of the tucked upper extremity in pronated position at the patient’s side. Figure reproduced from References 4 Bradshaw et al. with permission from the authors. 1 Hoffman MS, Roberts WS, Cavanagh D. Neuropathies associated with radical pelvic surgery for gynecologic cancer. Gynecol Oncol 1988;31:462– 6. no more than 1.5 cm from the fascial edge to minimise 2 Cardosi RJ, Cox CS, Hoffman MS. Postoperative neuropathies after major entrapment injury to these same nerves. pelvic surgery. Obstet Gynecol 2002;100:240–4. Shoulder braces, if used during steep Tredenlenburg, 3 Bohrer JC, Walters MD, Park A, Polston D, Barber MD. Pelvic nerve injury following gynecologic surgery: a prospective cohort study. Am J Obstet should be positioned over the acromio-clavicular joint, thus Gynecol 2009;201:e1–7. preventing brachial plexus injury. During surgery, the upper 4 Bradshaw AD, Advincula AP. Postoperative neuropathy in gynecologic arm must be pronated and padding should be adequately surgery. Obstet Gynecol Clin North Am 2010;37:451–9. 5 McDaniel GC, Kirkley WH, Gilbert JC. Femoral nerve injury associated with draped over the postero-medial elbow to prevent ulnar nerve the pfannenstiel incision and abdominal retractors. Am J Obstet Gynecol compression against the operating table (Figure 7). 1963;87:381–5. Arm boards should be placed at an angle no further upwards 6 Brasch RC, Bufo AJ, Kreienberg PF, Johnson GP. Femoral neuropathy secondary to the use of a self-retaining retractor. Report of three cases and than 90 degrees to avoid hyper-abduction nerve injury. review of the literature. Dis Colon Rectum 1995;38:1115–8. 7 Whiteside JL, Barber MD, Walters MD, Falcone T. Anatomy of ilioinguinal and iliohypogastric nerves in relation to trocar placement and low Medico-legal comment transverse incisions. Am J Obstet Gynecol 2003;189:1574–8. 8 Loos MJ, Scheltinga MR, Mulders LG, Roumen RM. The Pfannenstiel incision Inadvertent nerve injury can lead to litigation, with as a source of chronic pain. Obstet Gynecol 2008;111:839–46. important financial implications for the NHS. Nerve 9 Auroy Y, Narchi P, Messiah A, Litt L, Rouvier B, Samii K. Serious complications related to regional anesthesia: results of a prospective survey damage was the fourth most common treatment injury in in France. Anesthesiology 1997;87:479–86. New Zealand between 2005 and 2010 and accounted for 4.3% 10 Horlocker TT, Wedel DJ. Neurologic complications of spinal and epidural of all injury claims. An observational cohort study by Moore anesthesia. Reg Anesth Pain Med 2000;25:83–98. 11 Fardin P, Benettello P, Negrin P. Iatrogenic femoral neuropathy. et al. showed that orthopaedics was the most common Considerations on its prognosis. Electromyogr Clin Neurophysiol specialty associated with nerve damage, while obstetrics and 1980;20:153–5. gynaecology were ranked 7th and 9th place respectively.29 12 Chan JK, Manetta A. Prevention of femoral nerve injuries in gynecologic surgery. Am J Obstet Gynecol. 2002;186:1–7. Mal-positioning of the patient under general anaesthesia 13 Goldman JA, Feldberg D, Dicker D, Samuel N, Dekel A. Femoral neuropathy appeared to be the most important cause of nerve injury. subsequent to abdominal hysterectomy. A comparative study. Eur J Obstet Gynecol Reprod Biol 1985;20:385–92. 14 Irvin W, Andersen W, Taylor P, Rice L. Minimizing the risk of neurologic Conclusion injury in gynecologic surgery. Obstet Gynecol 2004;103:374–82. 15 Luijendijk RW, Jeekel J, Storm RK, Schutte PJ, Hop WC, Drogendijk AC, et al. Postoperative neuropathy following gynaecological surgery is a The low transverse Pfannenstiel incision and the prevalence of incisional hernia and nerve entrapment. Ann Surg 1997;225:365–9. significant cause of morbidity. The mechanism of 16 Miyazaki F, Shook G. Ilioinguinal nerve entrapment during needle intraoperative nerve injury involves a combination of suspension for stress incontinence. Obstet Gynecol 1992;80:246–8. compression, stretch, entrapment or nerve transection. 17 Benson JT, Griffis K. Pudendal neuralgia, a severe pain syndrome. Am J Obstet Gynecol 2005;192:1663–8. Nerves most commonly subjected to intraoperative injury 18 Neill C, Abdel-Fattah M, Ramsay IN. Sexual function and vaginal surgery. include nerves of the lumbosacral and brachial plexuses. The Obstetrician & Gynaecologist 2009;11:193–8. Incorrect placement of self-retaining retractors, patient 19 Connell K, Guess MK, La Combe J, Wang A, Powers K, Lazarou G, Mikhail M. Evaluation of the role of pudendal nerve integrity in female sexual mal-positioning and improper surgical incisions are major function using noninvasive techniques. Am J Obstet Gynecol contributors to intraoperative nerve injury. 2005;192:1712–7.

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